Provider Demographics
NPI:1649256355
Name:TIFFANY, JOHN RANDOLF (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RANDOLF
Last Name:TIFFANY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30170
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-7170
Mailing Address - Country:US
Mailing Address - Phone:302-428-4110
Mailing Address - Fax:
Practice Address - Street 1:2401 PHILADELPHIA PIKE
Practice Address - Street 2:
Practice Address - City:CLAYMONT
Practice Address - State:DE
Practice Address - Zip Code:19703-2430
Practice Address - Country:US
Practice Address - Phone:302-428-4110
Practice Address - Fax:302-798-6672
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005433207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEE62665Medicare UPIN
DE001847C90Medicare PIN